Throughout the United States, more than 1.4 million patients are currently under the care of a home health agency (HHA). Each year, in over 7 million home care episodes, approximately 20,000 HHAs provide care to a population at risk due to post-acute care or post-surgical clinical needs, diminished capacity for self-care, elderly and frail status, multiple chronic medical conditions, and complex at-home treatment regimens. Among all US home health episodes, 11% end with hospitalization, while approximately 28% of home health episodes among Medicare beneficiaries result in hospitalization. The goal of this study is to reduce avoidable hospitalizations in the home health setting through a risk-informed intervention program. This study is a continuation of an ongoing study we are conducting under the Agency for Healthcare Research and Quality program RFA-HS-07-003, Ambulatory Care Patient Safety Proactive Risk Assessment. Insights gained through that study will be used in the design of a comprehensive intervention program. The objectives for this study are to: [unreadable] * Develop, implement, and evaluate an intervention program to reduce HHA acute care hospitalization [unreadable] * Based on lessons learned through intervention implementation, develop and disseminate toolkits that will support wider adoption of successful practices [unreadable] * Disseminate study findings to other identified stakeholders. [unreadable] [unreadable] PUBLIC HEALTH RELEVANCE: In spite of significant efforts by CMS and the home care industry, the national risk adjusted acute care hospitalization rate for Medicare beneficiaries of 28% has been unchanged since 2005. This study offers a disciplined approach, informed through systems review of unplanned hospitalizations, for reducing avoidable admissions. [unreadable] [unreadable] [unreadable] [unreadable]